June 2018 Newsletter
Executive Director's Message
Back in May, the Commonwealth Fund released a  case study of Vermont's statewide effort to transform our health care system through an agreement with the Center for Medicare and Medicaid Services known as the all-payer model. The title of the piece is "Vermont's Bold Experiment in Community-Driven Health Care Reform" and it focuses almost exclusively on one element of Vermont's current health care reform effort - supporting the efforts of community health care providers like home agencies to help keep individual Vermonters as healthy as they can be through "care coordination." To me, the term "care coordination" is a fancy way of describing what happens when nurses and social workers pay close attention to someone with one or more chronic health conditions, with an eye toward addressing problems in their homes or their lives that might make them sicker or send them to the hospital. 
This work is not new to community providers like home health and hospice agencies.  Over the last decade, they have helped quietly transform Vermont's long-term care system so that more Vermonters are staying independent at home, when they might otherwise have been admitted to nursing homes. Home health maternal-child health nurses have changed the course of the lives of new mothers and babies all over the state through long-term relationships with families. 
The piece does a nice of job of emphasizing that what the accountable care organization adds to the effort are financial resources, training and technology to help professionals who work for different organizations collaborate with each other. As OneCare's chief medical officer Norm Ward says, "We have so many different community agencies that are in many ways driven by altruism and have budgets that are short already. We are trying to redistribute dollars from high-cost events to upstream community support services."
There is so much more work to do, but I am excited to see that outside experts are noticing that our provider-led health care reform effort is energizing hospitals to create new relationships with community partners to serve people beyond their institutions' walls.

Jill Mazza Olson
Executive Director
Beliveau Leads Visiting Nurse Association for Vermont and New Hampshire
Johanna Beliveau has joined Visiting Nurse and Hospice for Vermont and New Hampshire (VNH) as its Chief Executive Officer and President. She started her new role on June 18 after serving as as  Director of Quality, Patient Safety and Compliance at Mt. Ascutney Hospital and Health Center in Windsor, Vermont. She previously was Associate Chief Nursing Officer at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire.

"The Board of Trustees are very pleased that Johanna is joining VNH," said Board of Trustees Chair Gary Mayo. "She brings a wealth of experience and a truly collaborative outlook. She will help continue VNH's goal of providing excellent care at home in the communities we serve"

Vermont Update
The budget standoff between the Governor and legislative leaders ended late Monday evening when Governor Scott announced he will let the third state fiscal year 19 budget bill sent to him this year (H.16) become law without his signature. The bill will be effective on Saturday, June 30, one day before the fiscal year 19 starts on July 1. This is good news for the people served by home health and hospice agencies. The bill includes the two percent Medicaid rate increase for the home health, hospice and long-term care services for which the VNAs of Vermont advocated all session. 

Federal Update

Pre-Claim Review
The Centers for Medicare & Medicaid Services (CMS) recently proposed bringing back the pre-claim review demonstration. By adhering to this review process, home health agencies attest that they're meeting all certification and coverage requirements, ostensibly to help CMS reduce fraud and improve service to beneficiaries. Pre-claim review differs from prior authorization in that services can begin before a decision is rendered by the payer. Pre-claim review occurs after services start, but prior to a final claim being submitted.
CMS released a list of  frequently asked questions ,  which provide some insight into what may be coming for the home health agencies. The proposal is similar to a demonstration CMS ran in Illinois in 2016-2017, then paused without rolling out to other states as planned. Home health agencies had significant concerns during the first demonstration which CMS has only slightly modified it in three ways:
  1. The targeted states have been changed. Under this proposal the targeted states will include Illinois, Texas, Florida, Ohio, and North Carolina. Michigan and Massachusetts have been dropped under the new proposal;
  2. Home health agencies will have a choice of 100 percent pre-claim review, 100 percent post-payment review or a 25 percent payment rate reduction and potential claim review by the Recovery Audit Contractor; and
  3. HHAs can qualify for an exemption based on (unstated) performance standards.

This revised demonstration is scheduled to start no earlier than October 1, 2018 and last five years. 
The VNAs of Vermont shares the concern of our national partners about this effort. In its first iteration, pre-claim review had a sizable impact on patients and providers in Illinois, causing treatment delays and creating financial hardship for home health agencies. 
"The return of pre-claim revenue, even with revisions, is premature and may be entirely unnecessary,"  says  William A. Dombi, president of the National Association for Home Care & Hospice. "CMS has not taken advantage of what it learned during PCRD in Illinois in 2016-2017, where claims errors that related to documentation were ultimately correctible," he added. "The home care community also presented multiple and less burdensome alternatives to CMS that we believe will be equally or more effective than pre-claim review. CMS has not pursued or considered any of those alternatives," Dombi stated.  "It would be prudent for CMS to look to these alternatives before requiring home health agencies to take staff away from patient care to chase after endless paperwork. The Illinois experience demonstrated that any concern is limited to correctable paperwork errors."
In response to the CMS announcement, our national partners and colleagues in other state associations are launching a new advocacy effort to secure public release of all the data from the original project so they may conduct a thorough evaluation of the outcomes from that project and perhaps come up with suggestions for less burdensome alternatives.
Electronic Visit Verification

Last week, the U.S. House of Representatives passed  H.R. 6042 a bill that provides a state Medicaid programs another year to implement Electronic Visit Verification (EVV) for personal care services. Under current law, the deadline is January 1, 2019. The VNAs of Vermont supports the bill. While our member agencies all have electronic visit verification systems, the law imposes new data collection requirements. The Department of Vermont Health Access has been a collaborative and thoughtful partner in this effort, but unfortunately CMS has been slow to release the details necessary to fully evaluate the impact on the people who receive long-term care at home and the cost of the system changes.
Review of Home Health Claims for Services With Five to 10 Skilled Visits
The Department of Health and Human Services, Office of  Inspector General, has issued a revised  work plan  that includes a review of home health claims with five to 10 visits. Under the current payment system, if a home health agency provides four or fewer skilled visits, the agency is paid a standardized per-visit payment. The payments and the episodes are called Low Utilization Payment Adjustments (LUPA). When providing five or more visits, an agency instead receives a 60-day episode-of-care-based payment. 

Help OneCare Improve Health Care in Vermont

OneCare Vermont wants to understand issues and concerns from a consumer's perspective and is currently looking for volunteers who have Vermont Medicaid insurance to add their voices to its Board of Managers. The Consumer representatives from the three programs (Medicare, Medicaid, and Commercial programs) are part of a larger Board of Managers that works on ways to improve the health care system for all Vermonters.
All new members will receive training on our programs and their responsibilities as Board Members. Part of each Board Member's role is to attend a board meeting on the third Tuesday of every month from 4:30 to 7 pm.  These meetings rotate between OneCare Vermont offices in Colchester, Central Vermont Medical Center and Dartmouth Hitchcock Medical Center.  There is an option to call into the meetings, but in person attendance is encouraged as much as possible. 
Interested persons should have Vermont Medicaid insurance. To apply, send a short description of yourself to Spenser Weppler at spenser.weppler@onecarevt.org

Older Vermonters Task Force

The VNAs of Vermont, the  Vermont Association of Area Agencies on Aging  and several members of the SASH team  have been appointed by statute to an 18-member working group that will help develop an  "Older Vermonters Act " aligned with the federal  Older Americans Act , the  Vermont State Plan on Aging  and the  Choices for Care  program. Established this year by Act 172, the group will meet every other month starting in September to develop a report for the Legislature by Dec. 1, 2019, that addresses "the value of older Vermonters to the fabric of the State's communities, as well as the service and support needs that older Vermonters may have." 
What We're Reading

The Commonwealth Fund

Upcoming Events
Hosted by VNAs of Vermont

July 10 | 11:30 a.m. to 1 p.m.
Hosted by VNAs of Vermont
Third Thursdays beginning July 12
Hosted by Home Care Association of New Hampshire

July 24 | 8 a.m. to 4 p.m. and
July 25 | 8 a.m. to 12:30 .m. 
Hosted by Vermont Lung Association
Vermont Technical College, Williston
In-person event

VNAs of Vermont | www.vnavt.com | info@vnavt.org | 802-229-0579